multiple myeloma Flashcards
epidemiology
median age is 69 years
more prevalent in males and black pts
risk factors
radiation
chemicals (pesticides, herbicides, aromatic hydrocarbons and petroleum products, volatile organic compounds)
genetics (MGUS, increased w first degree relative)
obesity
suppressed immune system
what is multiple myeloma
plasma cell disorder
-antibodies created by B-cells are not functional
SLIMCRAB
sixty (>60% bone marrow plasma cells)
light chains (ratio >100)
MRI (>1 focal lesion >5mm)
calcium (serum calcium >1 mg/dL above ULN)
renal (creatinine clearance <40 mL/min or SCr >2mg/dL)
anemia (hemoglobin >2 mg/dL below LLN or <10 mg/dL)
bone (>1 osteolytic lesion)
consequences of bone disease
lytic lesions and fractures
anemia
hypercalcemia
initial work up
blood
24 hour urine
bone marrow
imaging
HIV/hep testing
serum viscosity
circulating plasma cells
echocardiogram
patient presentation
bone pain
pathologic fracture
frequent infection
anemia
rarely hyperviscosity and peripheral neuropathy
stage 1
serum beta 2 macroglobulin <3.5 mg/L
serum albumin >3.5g/dL
stage 2
not ISS 1 or 3
stage 3
serum beta 2 macroglobulin >5.5mg/L
Bisphosphonates- supportive care
bisphosphonate or denosumab therapy regardless of bone disease
-prefer denosumab in renal disease
-dental clearance before initiating
-continue therapy for 2 yearrs
anemia supportive care
erythropoietin or blood transfusions
infection supportive care
consider IVIG for patients with serious recurrent infection
-acyclovir proph for herpes zoster virus reactivation
-proph levofloxacin in newly diagnosed multiple myeloma patients
quick disease control while preserving bone marrow function
minimal residual disease leads to poorer outcomes
Triplet vs quadruplet regimen
gold standard: RVd lenalidomide (revlimid), bortezomib (velcade), dexamethasone
some patients may benefit from added daratumumab `
determining transplant eligibility
autologous transplant is preferred consolidation after induction chemotherapy
-collect enough cells for 2 transplants
*allogeneic can cure BUT high toxicity and mortality
consider:
-age
renal fxn
cardiac fx
performance status
caregiver support
daratumumab
MOA: antiCD38 monoclonal antibody
give SQ over IV
Premedications:
-steroid: dexamethasone or methylprednisolone
-acetaminophen
-antihistamine: diphenhydramine
-*montelukast for 1st dose to prevent respiratory reactions
Post medications
-methylprednisolone 20 mg x2 days after each dose for 1st cycle only
daratumumab side effects
infusion reactions
herpes zoster reactivation
hepatitis B reactivation
Lab interference
-SPEP/SIFE
-antibody detection test, antihuman globulin crossmatches, indirect antiglobulin tests
bortezomib
MOA: proteasome inhibitor–> inhib S20 causing apoptosis
SQ not IV (bad peripheral neuropathy)
ADEs:
-herpes zoster reactivation
-thrombocytopenia
-peripheral neuropathy
lenalidomide
immunomodulatory drug
ADEs:
birth defects
hematologic toxicity
thrombotic events
somnolence
increased risk of secondary malignancy
rash, skin toxicity
diarrhea
peripheral neuropathy (thalidomide)
***birth control, pregnancy tests for women of childbearing potential
anticoagulation
everyone gets
highest risk within 6 months of diagnosis
risk factors
-prior VTE
-high dose steroids
-obesity
-Central or tunneled catheter
-fracture
-ImiD use
anticoagulation therapy
enoxaparin 40 mg QD (preferred) or apixiban 2.5 mg BID –> partial response (50% reduction in m protein)–> aspirin 81 QD
dexamethasone
MOA: induce cell cycle arrest and apoptosis
steroid side effects
peripheral neuropathy management
vitamin b complex, duloxetine, or GABA analog
elotuzumab
MOa IgG monoclonal antibody
In combo with lenalidomide or pomalidomide
premedication: acetaminophen, diphenhydramine, famotidine, dexamethasone
side effects: infusion reactions, thrombocytopenia, herpes zoster reactivation
BITEs
step up dosing
CRS or ICANS–> subsequent doses at hospital
REMS program
CRS
increased cytokines due to T cell activation –> systemic inflammatory response
ICANS
disruption of the blood brain barrier and increased cytokines in CSF
treat with antiseizure meds, steroids, and supportive care
talquetamab toxicity
skin related
nail related
rash related
oral
weight loss
